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Regulatory Consultant II Pasadena, CA



Description

HPRS is responsible for leading California state regulatory initiatives across all functions statewide, as well as managing relationships and maintaining communications with stakeholders at all levels, both internally and externally.Researches, plans, implements, and monitors a broad portfolio of regulatory systems and initiatives to enable organizational compliance with all applicable Federal, state, and local regulations/laws. Advises the organization on all regulatory matters related to the Department of Managed Health Care (DMHC) and other state regulators. On an on-going basis, researches and interprets regulations and laws to establish standards, and may develop and/or deliver training and communications/change management relative to new standards. Assesses organizational systems (both physical and process or data related) to determine gaps in compliance and determine opportunities for remediation. Advises the organization on all compliance matters. May investigate violations of compliance policy, laws, regulations, etc. or conduct on-going monitoring and reporting to ensure remediation. May be responsible for project management relative to new compliance initiatives, products, or annual processes. HPRS is responsible for: Assessment of organizational systems and processes to ensure appropriate Health Plan oversight and survey readiness and determine gaps for remediation prior to regulatory surveys.All regulatory filings related to Health Plan's Knox-Keene license (ex. contracts, benefits, delivery systems, new products). Benefits interpretation to ensure statewide consistency in providing benefits to members and compliance with benefits provisions in contracts.

Essential Responsibilities:
HPRS is reponsible for Continued:
- Processing regulatory complaints in a timely manner and trending, reporting, and analyzing data related to these complaints.
- May be responsible for project management relative to new regulations, legislation, surveys, new products, or other issues involving state regulators.
- Developing and directing proactive regulatory strategies to support membership growth.
HPREO is responsible for:
Evaluating, interpreting, identifying and documenting business impacts and overseeing the implementation of the work as a result of Federal Commercial and Medicaid rules, regulations and laws across all functions and regions. This includes managing relationships and maintaining communications with stakeholders at all levels and management and/or oversight of ongoing operations required for participation on public exchanges.
HPREO is responsible for:
- Analysis of Federal commercial and Medicaid rules, regulations, laws and guidance to understand the business impacts.
- Ensure ownership for implementation.
- Serve as the FFM Exchange lead by overseeing end to end administrative operations and responding to questions and issues from the regulator.
- Monitor all product and rate filings.
- Lead the QHP recertification Community of Practice and oversee successful QHP recertification in all jurisdictions.
- Responsible for project oversight relative to implementation of new Federal Commercial and Medicaid regulations, rules or laws.
- Manages, creates, and maintains client relationships. An understanding of business operations and business functions and has some knowledge of how regulations impact business operations.
- May be responsible for oversight of business processes required for participation on public exchanges.
- Fosters comprehensive regulatory management through a series of activities to comply with all applicable regulations and statutes.Activities include:
- Planning: identifying regulatory accountabilities; identifying internal and external resources; developing regulatory analysis; participating on regulatory-related committees/work groups;
- Implementing: identifying regulatory requirements and conducting related analyses; creating or revising regulatory standards, policies, and procedures; and reporting on regulatory efforts and programs, and
- Validating: reviewing regulatory programs and content.
- Researches and stays abreast of regulations and statutes. Determines impacts of implementation of new regulations and statutes and required notifications, changes, and training. Communicates required changes, and leverages existing workgroups/etc. to facilitate required changes.
- Participate in the development of operational policies and procedures.



Qualifications:

Basic Qualifications:
Experience
Minimum five (5) years of health care experience or other applicable experience-health care operations, audit, finance, project management, regulatory or public policy development, investigations, information security, or insurance/health plan governance experience.
Education
- Bachelor's degree OR four (4) years of experience in a directly related field.

- High School Diploma or General Education Development (GED) required.
License, Certification, Registration
- N/A

Additional Requirements:
- Thorough knowledge of health care operations, regulatory policies, practices and systems and regional operational differences.
- Complete understanding of regulatory concepts.
- Full knowledge of health care industry practices and standards.
- Ability to draft and revise documents including analyses, and reports.
- Project management and/or consulting skills
- Years spent in law school resulting in a law degree may count as applicable job experience.

Preferred Qualifications:
- N/A


Primary Location: California,Pasadena,Regional Offices-Walnut 393 E. Walnut St.

Scheduled Hours (1-40): 40

Shift: Day

Working Days: Mon thru Friday

Schedule: Full-time

Job Type: Standard

Employee Status: Regular

Employee Group: Salaried, Non-Union, Exempt

Job Level: Individual Contributor

Job: Compliance / Privacy / Regulatory

Public Department Name: Health Plan Regulatory Services


External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.

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